16 January 2017

Have your say on local plans to limit the range of items available on NHS prescription

Engagement runs from Wednesday 4 January 2017 to Wednesday 1 February 2017

What are we planning to do?

The organisations that plan and buy health services for the people of Mansfield, Ashfield, Newark and Sherwood are planning changes to what is prescribed.

NHS Mansfield and Ashfield and Newark and Sherwood Clinical Commissioning Groups (CCGs) are asking the general public to comment about the following planned changes to prescribing and are asking if the changes should apply to ALL patients or if there are any vulnerable groups of patients who should still get these medicines and products on prescription because their health may be adversely affected by this change.

The CCGs currently plan to;

• Stop NHS prescriptions of gluten free foods. These are foods for people who are intolerant to gluten and who are generally coeliac.
• Stop NHS prescriptions of medicines not recommended for local use, including high cost branded medicines.
•  Stop NHS prescriptions of medicines to treat common minor illnesses that are suitable for self-care and can be managed using over-the-counter medicines.

It is the CCGs responsibility to regularly review areas of prescribing to identify where improvements in quality or cost can be made.

In September the CCGs told the public it was facing a significant financial shortfall. The CCG’s asked the public to help prioritise the services it provides.  A full copy of the findings of that survey is available on the CCG web sites: www.mansfieldandashfieldccg.nhs.uk or www.newarkandsherwood.nhs.uk

The public response indicated that the following areas of prescribing are seen as a low priority when compared to a range of other services.

• Prescribing of gluten free foods

• Use of restricted use medicines including high cost branded medicines.
• Medicines for self-care (over-the-counter medicines)

The CCGs are asking the public to comment about the changes before they are introduced.

• Why are we planning to stop NHS prescriptions of gluten-free foods?

In 2015, the CCGs carried out a survey of the general public for comments about plans to limit to eight per month, the number of gluten free items prescribed for people who live in Mansfield and Ashfield and Newark & Sherwood areas.

Almost ninety per cent of the people who responded were those in receipt of gluten free products who supported the continuation of NHS funded gluten free prescriptions.

As a result of the most recent public survey about NHS priorities and the current financial position, the CCGs have further reviewed the provision of gluten free products and are now planning to stop funding them altogether.

• Gluten free foods are items that do not contain the protein gluten. Gluten is found in grains such as wheat, barley and rye.
• Approximately one per cent of people have gluten intolerance. Gluten free food is currently prescribed on the NHS for adults and children with a confirmed diagnosis of Coeliac Disease or Dermatitis Herpetiformis who require a gluten free diet. In these people, gluten can cause health problems. Symptoms vary and can include abdominal pain, diarrhoea, nausea, weight loss, headaches and osteoporosis. There is no cure for coeliac disease, but switching to a gluten-free diet can help symptoms and to help avoid any long term health problems.
• Food is not provided on prescription for many other patients, such as patients with diabetes, lactose intolerance or those with allergies. Historically gluten free foods were provided on prescription due to their limited availability and high cost in general stores, however the availability and range of foods has changed significantly over the past few years. All major supermarkets and many local shops now stock gluten free foods, and the range is expanding all the time.
• The cost to the NHS of prescribing gluten free foods is roughly twice the cost of gluten free food items available in a supermarket. Table 1 shows the comparative cost of gluten free foods on the NHS compared to supermarkets as well as gluten containing equivalents.

Tale 1: Comparative costs to provide gluten free foods for an adult male per month.

Source: NHS PrescQIPP Bulletin February 2015

• The prescribing of gluten free foods varies greatly across Mansfield and Ashfield and Newark & Sherwood, with many patients now choosing to buy their food products. Based on national figures, locally approximately 3,250 people are gluten intolerant and could benefit from gluten free foods.
• 1,300 patients currently get these foods on prescription, so there is an unequal service being offered to local people. This includes a small number of children.
• The current policy means that people receive a maximum of eight items per month of staple items such as bread, flour or pasta.
• The CCGs recognise the importance to everyone of a healthy balanced diet including fibre, fruit and vegetable and oily fish.
• People are encouraged to limit the parts of their diet that contain saturated fat, sugars and salt. Potatoes and rice are gluten free and are advised as part of a healthy balanced diet for everyone.
• Gluten, as a protein is not considered essential as part of a healthy diet and can be replaced by a range of other food items which are available as part of a healthy diet for everyone.
• In the last year, £165,000 was spent on gluten free foods by your local NHS.

Who will this affect?

The CCG anticipates that if gluten free foods were no longer available on prescription, for an average male, this would increase their food bill by an average of £5 per month if they were to buy the equivalent 8 items from a supermarket.

•  Why are we planning to stop NHS prescriptions for branded medicines (where a lower cost non-branded medicine is available) and medicines not recommended for local use?

• Restricted use medicines are a range of medicines that cost more and either:
  • contain the same active ingredient (for example Nurofen instead of ibuprofen or Panadol instead of paracetamol).
  • or work in the same way for example different hay fever preparations.
• The CCGs appreciate the importance of the best quality medicines that have the best effect for patients, and acknowledge that there is a lot of variation in prescribing so people are not currently receiving an equal service.
• The CCGs recognise that they need to make sure that medicines not recommended or not approved for local use are not being prescribed.
• The CCG has estimated that the cost of prescribing non approved or branded medicines is roughly £1.2 million per year.
• Examples of cost differences between branded and non-branded (generic) medicines and formulary and restricted use medicines are given below.

* Monthly cost of medicine at standard treatment dose

Funds saved by stopping the prescribing of these medicines could be used to support other clinical services.

Who will this affect?

• Some patients are already receiving a restricted use medicine. It is planned that their treatment will be reviewed to replace it with an approved medicine. Therefore this change will affect a small number of patients who do not want to receive the approved medicine. These patients will be reviewed on a case by case basis.
• Non-formulary or branded medicines do not offer better health benefits; therefore people will not have any adverse effects from this change.
• Some people need to be maintained on the same brand of medicine to keep their condition stable e.g. treatment of epilepsy or confirmed allergy. If there is a clinical need to prescribe a branded or non-formulary medicine, then the doctor will decide on the best treatment for the patient and record this in the patient’s record.

• Why are we planning to stop NHS prescriptions for medicines to treat minor illnesses that are available over-the-counter and are suitable for self-care?

• It is proposed that the NHS no longer funds prescriptions for items such as paracetamol, hay fever treatments or other items which are readily available over-the-counter but are still routinely prescribed.
• Self-care is a term used by the NHS that focuses on the need for people to do all they can to manage their own health and wellbeing

• Community Pharmacists offer advice on many minor illnesses, and stock a wide range of inexpensive treatments. There is no need for an appointment and many pharmacies are open long hours over seven days a week.

• There are many conditions that are suitable for self-care including short term pain relief, coughs and colds, hay-fever and constipation. A wider list is included in appendix A.

• Currently around 20% of GP time and 40% of their total consultations are used for these common minor conditions that could be treated without seeing a GP. Individuals that care for themselves have better health and reduced demand for services.

• Locally, the NHS spends £1.5 million on medicines for minor illnesses. It is the view of the CCGs that if more people chose to self-care, the NHS could redirect this money to other clinical services, and GP consultation time could be better used to help patients that require treatment for more complex conditions.
• There is no planned change to the management of long-term conditions. The GP Practice will continue to prescribe medicines where appropriate to manage long-term or more complex medical conditions.
• Many Community Pharmacies offer the Pharmacy First service. Pharmacy First is a minor ailments service which is open to people registered with a local GP that are normally exempt from paying prescription charges. It means that those eligible can see a qualified health professional at a pharmacy to provide free advice and treatment for many minor illnesses.

Who will this affect?

This change will affect people seeking treatment from their GP for minor conditions.

Advice and treatment is available through local Community Pharmacies and some products such as simple pain killers are also widely available at supermarkets and general stores.

 Who is leading this engagement?

It is being led by NHS Mansfield and Ashfield CCG and NHS Newark and Sherwood CCG who are working in partnership across mid-Nottinghamshire. These organisations plan and pay for the healthcare services for our communities, ensuring best value for money for our patients.

 How can people feedback about our plans.

The CCGs plan to engage with the public about these plans between 4 January 2017 and 1 February 2017.

This will include:

• A survey that can be completed either on-line or paper based for return using a freepost address

What are the planned changes?

1. The CCG intends to stop prescribing gluten free foods for all patients.
2. The CCG intends to stop prescribing all branded medicines (where a lower cost non-branded medicine is available) and restricted use medicines for all patients.
3. The CCG intends to stop prescribing medicines for self-care for all patients.

 You are being asked if these policies should apply to ALL patients or if there are any vulnerable groups of patients who should still get these medicines and products on prescription because their health may be adversely affected by this change.

If you think there are exceptions to the policies, we would like to hear why you feel these groups of people should receive these medicines on prescription.

As commissioners (Mansfield & Ashfield Clinical Commissioning Group; CCG and Newark and Sherwood CCG) we plan and buy health care services for our local population. We have a legal duty to live within our means and we need to save around £20 million this financial year, roughly twice our normal savings requirement. This is likely to increase over the next few years. We need to ensure that there is enough money to maintain high quality and safe services for future generations.

These changes are being planned to make sure we have a consistent policy in place across Mid-Nottinghamshire.

These changes are also being made to make better use of healthcare services, ease the pressure on general practice and make NHS money go further.